Provider Demographics
NPI:1114981206
Name:KENNEDY, RAE L (MD)
Entity Type:Individual
Prefix:
First Name:RAE
Middle Name:L
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 854
Mailing Address - Street 2:MC A410
Mailing Address - City:HERSHEY
Mailing Address - State:PA
Mailing Address - Zip Code:17033-0854
Mailing Address - Country:US
Mailing Address - Phone:800-233-4082
Mailing Address - Fax:
Practice Address - Street 1:670 CHERRY DR
Practice Address - Street 2:STE 202/204
Practice Address - City:HERSHEY
Practice Address - State:PA
Practice Address - Zip Code:17033-2003
Practice Address - Country:US
Practice Address - Phone:800-233-4082
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-14
Last Update Date:2022-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD427432207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1013999740001Medicaid
095457Medicare ID - Type Unspecified
PA1013999740001Medicaid